Coroner's concerns
Coroner’s Concerns (source excerpt)
i. The inaccuracy and unreliability of incident recording at Alexander House; ii. Incomplete documentation in respect of the care provided to residents at Alexander House. iii. Honesty and integrity of staff working at Alexander House. iv. The absence of appropriate and robust training for the Registered Manager at Alexander House in respect of safeguarding investigations...
View full coroner's concerns
i. The inaccuracy and unreliability of incident recording at Alexander House;
ii. Incomplete documentation in respect of the care provided to residents at Alexander House.
iii. Honesty and integrity of staff working at Alexander House.
iv. The absence of appropriate and robust training for the Registered Manager at Alexander House in respect of safeguarding investigations to ensure thorough and complete investigation and transparency of investigation.
v. The absence of any form of independent monitoring within the home to provide independent oversight of any events occurring within communal areas.
vi. The absence of any form of professional regulatory body (over and above the CQC) to ensure that staff tasked with caring for vulnerable elderly individuals are suitably qualified and consistently deliver safe, high-quality and effective care to provide oversight and accountability of those individuals.
Report sections
Investigation and inquest
On 17 September 2025 I commenced an investigation into the death of John Bryan WETTON aged 92. The investigation concluded at the end of the inquest on 11 May 2026. The conclusion of the inquest was that John Bryan Wetton died as a consequence of injuries sustained in a traumatic event, it has not been possible to determine the nature or mechanism by which John sustained his injuries or whether there was any third party involvement in the traumatic event.
Circumstances of the death
In the early hours of the 5th August 2025, John Bryan Wetton was admitted to Huddersfield Royal Infirmary where investigations revealed that he had suffered two bleeds to his brain, a periprosthetic fracture to his right hip, bruising to his left eye and a small laceration to his nose. John’s injuries were caused by a traumatic event and are consistent with John having suffered a fall in the hours prior to his admission to hospital. It has not been possible to determine the nature of the event which caused John’s injuries, nor has it been possible to determine whether or not the injuries were as a consequence of third party involvement. Had John fallen, he would have been unable to get up without the assistance of more than one person and staff caring for John that evening, assert that he did not suffer a fall.
In the period following his admission, John’s condition continued to deteriorate and on the 21st August 2025, John was placed on the Last Days of Life pathway and passed away in Hospital at 0245 hours on the 26th August 2025.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
Copies sent to
Calderdale Adult Social Care [REDACTED] [REDACTED]
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